Discretion of doctors threatened as patients' access to guns questioned

January 28, 2013|By Kevin Rector, The Baltimore Sun

Sitting around a broad table in a nondescript office in Reisterstown last week, more than a dozen mental health advocates, medical professionals and law enforcement officials stared tensely at one another.

Nearly a month after the state-created task force issued a report outlining its findings on psychiatric patients' access to firearms, several members were questioning a key recommendation — that mental health professionals should be required to report to law enforcement all patients who threaten suicide.

"Some people say they would be reporting every single person who walked through their door," said Dan Martin, a panel member representing the Mental Health Association of Maryland.

Laura Cain, of the Maryland Disability Law Center, insisted that reporting of suicidal threats hadn't been fully considered, "because we would have objected to that."

The meeting was in many ways a microcosm of the national debate in the wake of the massacre of 20 children and six adults at Sandy Hook Elementary School in Connecticut. That debate hinges on the responsibility of doctors, addiction counselors and other mental health professionals to maintain patient confidentiality — and to protect public safety, to the extent that they can.

As law enforcement officials and politicians push new gun control measures, mental health providers say they feel caught in the middle and warn that some proposals would endanger their relationships with patients.

The Maryland General Assembly is considering legislation, based on the task force's work, to require mental health professionals to report patients who make verbal or physical threats of suicide or serious violence. Law enforcement would use the information to investigate and potentially seize any guns the patients own.

New York recently approved legislation implementing a similar requirement.

Dr. Paul Appelbaum, past president of the American Psychiatric Association, said such efforts strip away the discretion of psychiatrists and other mental health professionals to decide the best course of action after hearing a troubling statement from a patient.

"What's really different about this new-wave approach is that it turns a clinical issue into a legal issue, and it takes discretion out of the hands of the clinician by requiring a mandatory breach of the privacy of the medical and mental health setting," said Appelbaum, director of the division of law, ethics and psychiatry at Columbia University.

"And it does all this in a structure, in a framework, that many professionals, mental health professionals, including me, think is not likely to be effective in substantially reducing gun violence and runs a very high risk of being counterproductive,"he added.

At Thursday's meeting in Reisterstown, the requirement to report all suicidal threats was similarly criticized by a handful of panel members as an overly strict standard that would unnecessarily limit clinicians' options. The recommendation that patients' threats toward others be reported to police was not questioned, as members said it is in line with existing professional standards.

Leaders of the task force, including Patrick Dooley, chief of staff for state Health Secretary Joshua Sharfstein, and Capt. Jack McCauley, commander of the Maryland State Police licensing division, acknowledged the recommendations would have to be fine-tuned.

Del. Samuel I. Rosenberg, a Baltimore Democrat who attended the meeting, said he intends to file legislation during the current General Assembly session based on the task force report.

The issue of mental health counseling and gun violence has commanded the nation's attention in recent months, following some mass shootings.

In Colorado, a university psychiatrist has been sued by the wife of a victim in the mass shooting at a movie theater in a Denver suburb. The wife contends the alleged gunman told the psychiatrist about his violent inclinations and that the doctor didn't do enough to work with police to stop him.

Unveiling his gun control proposals,President Barack Obama clarified that there is no federal law preventing psychiatrists from reporting threats. And New York Gov. Andrew Cuomo garnered widespread media attention when his state recently managed to pass legislation requiring such reporting. U.S. Sen. Barbara A. Mikulski of Maryland said at a recent Senate hearing on the mental health care system that a new balance must be reached between protecting patients' privacy and ensuring that they receive proper treatment before they turn to violence.

Gov. Martin O'Malley has proposed a broad gun control and mental health package that would require judges who find a patient to be dangerous at an involuntary commitment review hearing to report that finding to police, so they could review the patient's gun ownership and perhaps seize weapons.